Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness - 54192IN0020011 Health Insurance Plan
CareSource Indiana, Inc. health insurance plan with the Plan ID 54192IN0020011. The plan is called Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.04% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.96% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 54192IN0020011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | CareSource Indiana, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 54192IN0020011-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 54192IN0020011-00 Standard On Exchange Plan - 54192IN0020011-01 Open to Indians below 300% FPL - 54192IN0020011-02 Open to Indians above 300% FPL - 54192IN0020011-03 73% AV Silver Plan - 54192IN0020011-04 |
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| Last Plan Update Date | Fri, 13 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, 54192IN0020011-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Exclusions: nan Injury as a result of chewing or biting is not considered an accidental injury. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan Cost share driven by provider/setting |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan Cost share driven by provider/setting |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period Exclusions: nan Manipulation Therapy is limited to 12 visits. Physical Therapy is limited to 20 visits. Physical Therapy imits are combined with services delivered under Outpatient Rehab or Habilitation Services. |
YES | $75.00 |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | $500.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: nan One wig per benefit period. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Limited to one pair of glasses or contact lenses per benefit year. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Exclusions: nan nan |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Physical Therapy, Occupational Therapy, and Speech Therapy limited to 20 visits each per benefit period. |
YES | $35.00 |
100.00% |
| Hearing Aids
Exclusions: nan nan |
NO | ||
| Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period Exclusions: nan A visit equals at least 4 hours. Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $250.00 Copay after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan Cost share driven by provider/setting |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). |
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan Cost share driven by provider/setting |
YES | $40.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan Cost share driven by provider/setting |
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan Cost share driven by provider/setting |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $35.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Exclusions: nan Physical, Occupational, and Speech Therapy (including Post Cochlear Rehab) limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Manipulation Therapy is limited to 12 visits. Pulmonary Therapy limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $35.00 |
100.00% |
| Private-Duty Nursing
Limit: 100.0 Visit(s) per Year Exclusions: nan A visit equals 8 hours. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan Cost share driven by provider/setting |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: Excludes all other reconstructive services that are not specifically outlined in Covered Services. Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Exclusions: nan Physical Therapy and Occupational Therapy limited to 20 visits each per benefit period. |
YES | $35.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Exclusions: nan Cost share driven by provider/setting |
YES | $35.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Limit: 2.0 Visit(s) per Year Exclusions: nan nan |
YES | $40.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan nan |
YES | 0.00% |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period Exclusions: nan nan |
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $75.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $500.00 Copay per Stay after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan Cost share driven by provider/setting |
YES | $35.00 |
100.00% |
| Transplant
Exclusions: nan Quantitative limit units apply, see Summary of Benefits and Coverage. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $70.00 |
$70.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan Cost share driven by provider/setting |
YES | $200.00 Copay after deductible |
100.00% |
Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan Variant 54192IN0020011-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700435155596475 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.991499921181986 |
| First Tier Utilization | 100% |
| Formulary ID | INF004 |
| Formulary URL | URL |
| HIOS Product ID | 54192IN002 |
| Import Date | 2024-09-13 01:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 54192 |
| Issuer Marketplace Marketing Name | CareSource |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | INN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services Only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 54192IN0020011-00 |
| Plan Marketing Name | Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $6,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,200 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 54192IN0020011 |
| State Code | IN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $12000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $12000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, 54192IN0020011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness, 54192IN0020011 Health Insurance Plan, 54192IN0020011
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Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, 54192IN0020011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (54192IN0020011) Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs?
Does (54192IN0020011) Health Insurance Plan, Variant (54192IN0020011-00) have Out Of Country Coverage?
Does (54192IN0020011) Health Insurance Plan, Variant (54192IN0020011-00) have Out of Service Area Coverage?
Does (54192IN0020011) Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Asthma?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Heart disease?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Depression?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Diabetes?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Low back pain?
Does Low Premium Silver 6000 $3 Generic Drugs Adult Vision & Fitness Health Insurance Plan, Variant (54192IN0020011-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API